Abstract
Staphylococcus aureus infection is a persistent threat in resource-restricted settings in southeast Asia but informative data about this disease remain limited. We analyzed characteristics, management, and predictors of outcome in severely septic patients with community-onset S. aureus infection in northeast Thailand. We performed a prospective, multicenter observational cohort study of community-onset S. aureus sepsis in four referral hospitals recruiting patients at least 14 years of age admitted between March 2010 and December 2013. One hundred and nineteen patients with severe staphylococcal sepsis were enrolled. Diabetes was the most common underlying condition. Methicillin-resistant infection was rare. Twenty-eight-day mortality was 20%. Ninety-two percent of patients received appropriate antibiotic therapy and 82% were administered intravenous fluids on the first hospital day, although only 14% were managed in an intensive care unit (ICU). On univariable analysis, clinical variables at enrollment significantly associated with death at 28 days were coagulopathy or respiratory failure. Plasma interleukin (IL)-8 concentration alone accurately predicted mortality (area under the receiver operating curve = 0.82, 95% confidence interval = 0.73–0.90). In multivariable analysis, addition of IL-8 concentration to a mortality prediction model containing clinical variables further improved the predictive ability of the model. We conclude that severe staphylococcal sepsis in northeast Thailand causes significant mortality. Diabetes is a common preexisting condition and most patients are managed outside the ICU even if they receive vasoactive/inotropic agents or mechanical ventilation. While clinical factors apparent on presentation including coagulopathy and respiratory failure predict death, plasma IL-8 improves this prediction.
Highlights
Staphylococcus aureus is an established pathogen in resource-restricted regions of southeast Asia1–4 and an increasingly important contributor to the substantial global burden of severe sepsis—the syndrome of infection accompanied by a dysregulated host inflammatory response and organ dysfunction.5,6 Staphylococcus aureus expresses numerous virulence determinants that result in infection of the skin and soft tissues, respiratory tract, bones, joints, and endovasculature leading to sepsis.7,8 Yet few studies address management of hospitalized patients with severe sepsis—due to S. aureus or to other pathogens—in resource-restricted settings in southeast Asia or elsewhere
We found that the model including IL-6 had lower Akaike information criterion (AIC) and Bayesian information criterion (BIC) scores than the baseline model (Table 3) and the two models were significantly different by the likelihood ratio test (P = 0.004)
The major findings from our study are that severe staphylococcal sepsis causes significant mortality despite appropriate antibiotic therapy; diabetes is a common preexisting condition; most patients are managed outside the intensive care unit (ICU) even if they receive vasoactive/inotropic agents and mechanical ventilation; and while clinical factors apparent on presentation including coagulopathy and respiratory failure predict death, plasma IL8 significantly improves this prediction
Summary
Staphylococcus aureus is an established pathogen in resource-restricted regions of southeast Asia and an increasingly important contributor to the substantial global burden of severe sepsis—the syndrome of infection accompanied by a dysregulated host inflammatory response and organ dysfunction.. Few studies address management of hospitalized patients with severe sepsis—due to S. aureus or to other pathogens—in resource-restricted settings in southeast Asia or elsewhere. In a resource-restricted environment, robust data about presentation, management, and outcomes of these patients are essential to inform strategies to allocate scarce resources judiciously and improve outcomes.. In a resource-restricted environment, robust data about presentation, management, and outcomes of these patients are essential to inform strategies to allocate scarce resources judiciously and improve outcomes.9,10 Central to this process is understanding what factors may predict outcome. The predictors of outcomes such as death from severe sepsis in resource-restricted settings are largely unknown
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